Resource UnitTopic : PHEOCHROMOCYTOMA

General Objectives: After 1 hour of student-clinical instructor interaction, the BSN- 4KK students will be able to acquire basic knowledge, beginning skills, and positive attitude towards the concept and management of Pheochromocytoma.

Specific Objectives Content Methodology Time Allotment

Resources Evaluation

Specifically, the BSN-4KK students will be able to:

1.) State correctly the related terms to Pheochromocytoma through a pre-conditioning activity of modified charade entitled “Body Language”

Mechanics:

Three students will be randomly picked from the whole group. Each of them will be given a word to spell-out using only the movements of their buttocks. Another three students will be randomly picked to be the players and answer the charade. A description of the word will be flashed to guide the players. They will be given 60 seconds each to answer correctly. Failure to do so means that the player has to face a random consequence.

• Activity-Based Learning: Cooperative Learning (Gaming)

• 5 minutes

• Computer• Printer• D. L. P.• Microsoft Powerpoint• Internet• Clinical Instructor• Students

•After 5 minutes of pre-conditioning activity, the BSN-4KK students were able to correctly match the related terms to state correctly the related terms to Pheochromocytoma through a pre-conditioning activity entitled “Body Language”

Related Terms and their Definitions:

PheochromocytomaIs a rare, cathecholamine-secreting tumor derived from Chromaffin cells; may precipitate life-threatening hypertension, or cardiac arrythmias.

Chromaffin CellsAre neuroendocrine cells found in the medulla of the adrenal gland and in other ganglia of the sympathetic nervous system. They release the neurotransmitters catecholamines; norepinephrine, and epinephrine into the systemic circulation.

CatecholamineHigh catecholamine levels in blood are associated with stress, which can be induced from psychological reactions or environmental stressors. In the human body, the most abundant catecholamines are epinephrine, norepinephrine, and dopamine.

2.) Acquire a quick review of the Anatomy and Physiology of the Adrenal glands.

Adrenal Glands

A. Structure of the Glands

1. The adrenal glands are shaped like

pyramids.

2. The two parts of an adrenal gland are

the cortex and medulla.

3. The adrenal medulla consists of irregu-

larly shaped cells grouped around blood

•Traditional Oral Essay Lecture

• 10 minutes

• Computer• Printer• D. L. P.• Microsoft Powerpoint• Internet• Clinical Instructor• Students

•After 10 minutes of Traditional Oral Essay Lecture, the BSN-4KK students were able to acquire a quick review of the Anatomy and Physiology of the Adrenal Glands

vessels.

4. The adrenal cortex is composed of

closely packed masses of epithelial layers.

5. The three layers of the adrenal cortex

are the outer zona glomerulosa, the middle

zona fasciculata, and the inner zona reticu-

laris.

B. Hormones of the Adrenal Medulla

1. The two hormones released by the

adrenal medulla are epinephrine and nor-

epinephrine.

2. The actions of epinephrine and norepi-

nephrine are increased heart rate, increased

force of cardiac muscle contraction, ele-

vated blood pressure, increased breathing

rate and decreased activity of the digestive

system

3. The secretion of epinephrine and norep-

inephrine are controlled by the sympa-

thetic nervous system.

C. Hormones of the Adrenal Cortex

1. Introduction

a. The adrenal cortex produces more

than 30 different steroids.

b. The most important adrenal cortical

hormones are aldosterone, cortisol, and

certain sex hormones.

2. Aldosterone

a. Aldosterone is secreted by the zona

glomerulosa and is called a mineralocorti-

coid because it helps regulate the concen-

tration of mineral electrolytes.

b. The actions of aldosterone are regula-

tion of concentration of extracellular elec-

trolytes by conserving sodium ions and ex-

creting potassium ions.

c. The secretion of aldosterone is con-

trolled by electrolyte concentrations in

body fluids and the renin-angiotensin

mechanism

3. Cortisol

a. Cortisol is secreted by the zona fascilu-

lata and is called a glucocorticoid because

it affects glucose metabolism

b. The actions of cortisol are to decrease

protein synthesis, increase fatty acid re-

lease, and simulate glucose synthesis from

noncarbohydrates.

c. The secretion of cortisol is controlled

by CRH.

4. Sex Hormones

a. The sex hormones are secreted by the

zona reticularis.

b. The actions of the sex hormones are to

supplement sex hormone from the gonads.

c. Examples of sex hormones are andro-

gens such as testosterone.

3.) Discuss properly the Pathophysiology of Pheochromocytoma

Pheochromocytoma is a tumor that is usually benign and originates from the chromaffin cells of the adrenal medulla. In 90% of clients, the tumor arises in the medulla; in the remaining clients, it occurs in the extra-adrenal chromaffin tissue located in or near the aorta, ovaries, spleen, or other organs.

Pheochromocytoma may occur at any age, but its peak incidence is between 40 and 50 years of age, affecting men and women equally. 10% of tumors are bilateral, 10% are malignant. Because of the high incidence of pheochromocytoma in family members of affected people, the patient’s family members should be alerted and screened for this tumor. It should be considered a possibility in clients who have medullary thyroid carcinoma and parathyroid hyperplasia or tumor.Pheochromocytoma is the cause of high blood pressure in 0.1% of patients with hypertension. Although it is uncommon, it is one form of hypertension that is cured by surgery; however, without detection and treatment, it is usually fatal.

• Formal Discussion

• 10 minutes

• Computer• Printer• D. L. P.• Microsoft Powerpoint• Internet• Clinical Instructor• Students

•After 10 minutes of Traditional Oral Essay Lecture, the BSN 4KK students were able to properly discuss the Pathophysiology of pheochromocytoma.

4.) Discuss thoroughly the Clinical Manifestations of Pheochromocytoma

The clinical manifestations of Pheochromocytoma result from excessive catecholamine secretion by the tumor. The biologic effects of catecholamines are well known. Stimulation of alpha adrenergic receptors result in elevated blood pressure, increased cardiac contractility, glycogenolysis, gluconeogenesis, and intestinal relaxation. Stimulation of beta-adrenergic receptors results in an increase in heart rate and contractility

The typical triad of symptoms is headache, diaphoresis, and palpitations in the patient with hypertension.

Hypertension and other cardiovascular disturbances are common.

Blood pressures exceeding 250/150 mmhg have been recorded. Such BP elevations are life-threatening, and can cause severe complications such as stroke, and acute renal failure. Postural hypotension occurs in 70% of patients with untreated pheochromocytoma.

• Formal Discussion

• 5minutes • Computer• Printer• D. L. P.• Microsoft Powerpoint• Internet• Clinical Instructor• Students

•After 5 minutes of formal discussion, the BSN 4KK students were able to thoroughly discuss the clinical manifestations of Pheochromocytoma.

5.) Discuss correctly the Management of Pheochromocytoma.

Signs of sympathetic nervous system overactivity occur in association with marked elevation of blood pressure. These sign s can be associated with the five H’s: hypertension, headache, hyperhidrosis, hypermetabolism, and hyperglycemia.

Assesment and Diagnostic Tests

a.) Catecholamine levels

Measurements of plasma levels of catecholamines are the most direct and conclusive tests for hyperactiv-ity of the adrenal medulla.Epinephrine: 100 pg/mlNorepinephrine: less than 100 to 550 pg/ml

b.) Urine sample for Vanillylmandelic acid

VMA: 75-200 mEq/L in 24 hours

c.) Clonidine suppression test

PO clonidine 0.3 mg will suppress

• Formal Discussion

• 30 minutes

• Computer• Printer• D. L. P.• Microsoft Powerpoint• Internet• Clinical Instructor• Students

•After 30 minutes of formal discussion, the BSN 4KK students were able to correctly discuss the management of Pheochromocytoma.

catecholamine secretion in hyper-tensive clients and not in patients with pheochromocytoma.

d.) Imaging studies such as CT, MRI, and ultrasonography may also be carried out to localize the tumor, and to determine whether more than one tumor is present.

Medical ManagementPharmacologic therapyThe client may be moved to the ICU for close monitoring of ECG changes and careful administration of alpha adrener-gic blocking agents (Phentolamine), or smooth muscle relaxants (Sodium Nitro-prusside) to lower BP immediately.Phenoxybenzamine (Dibenzyline), a long acting alpha blocker, may be used af-ter BP is stable to prepare the client for surgery. Calcium channel blockers such as nifedipine (Procardia) are tolerated by clients and have reduced perioperative fluid requirements.

Surgical ManagementAdrenalectomy is the surgical removal of the tumor and is the definitive treatment of

pheochromocytoma.Corticosteroid therapy may be required on the first few days or weeks after adrenalectomy.

Nursing ManagementThe patient who has undergone surgery to treat pheochromocytoma has experienced a stressfull journey perioperatively. Al-though it is usually expected that all pheochromocytoma tissue has been re-moved, there is a possibility that other sites were undetected and that attacks may recur. The patient is monitored for several days in the intensive care unit with special attention given to ECG changes, arterial pressures, fluid and electrolyte balance, blood and glucose levels. Several IV lines are inserted for administration of fluids and medications. Promoting Home and Community-Based CareTeaching Patients Self-CareDuring the preoperative and postoperative phases of care, the nurse informs the pa-tient about the importance of follow-up monitoring to ensure that pheochromocy-toma does not recur undetected. After adrenalectomy, use of corticosteroids may be needed. Therefore, the nurse instructs

the patient about their purpose, the medi-cation schedule, and the risks of skipping doses or stopping their administration abruptly.It is important to teach the patient and family how to measure the patient’s blood pressure and when to notify the physician about changes in blood pressure.

Continuing CareA follow-up visit from a home care nurse may be indicated to assess the patient’s postoperative recovery, surgical incision, and compliance with the medication schedule. This may help reinforce previous teaching about management and monitor-ing. The home care nurse also obtains blood pressure measurements and assists the patient in preventing or dealing with problems that may result from long-term use of corticosteroids.Because of the risk of recurrence of hyper-tension, periodic check-ups are required, especially in young patients and those whose families have a history of pheochro-mocytoma. The patient is scheduled for periodic follow-up appointments to ob-serve for return of normal blood pressure and plasma and urine levels of cate-cholamine.

DELTOID MUSCLEDORSOGLUTEAL MUSCLE